Diagnostic or therapeutic?

This is a new patient, 58 female who presents with acute on chronic left hip pain. She is slow to rise from the waiting room chair and limps to approach my room. She describes two months of increasing left hip pain.

There are two components – a deep pain with a pointing sign to the groin crease and a pain that tracks down the lateral thigh. There was no recalled trauma or prior history.

On examination there was both tenderness over the greater trochanter, a positive Trendelenburg sign and positive impingement tests (FABER and flexed int/ext rotation). Interestingly this patient had previous had a plain radiograph and CT at St Elsewhere which were reported as essentially normal. However this was not in keeping with her symptoms and signs of significant left hip pain and disability.

I felt this was a combination of trochanteric bursitis/gluteal tendonosis and a internal hip derangement. After a talk that I thought there were two problems, without prophesying about what was the chicken or egg, we decided to organise MRI and perform a diagnostic/therapeutic trochantric bursa injection.

There was only slight benefit to the injection for the patient with a persistence of the deep and positional left hip ache. MRI demonstrated significant chondral loss, fissuring and bone oedema, out of keeping with the radiograph and CT. There was no identified labral injury. Now I feel this is a right gluteal and tensor fasciae latae tendonosis as a sequelae to left hip chondral loss.